Enhancing the Patient Experience in the Head & Neck Center Pheba Philip Office of Performance Improvement Head & Neck Center.

Enhancing the Patient Experience in the Head & Neck Center

Pheba Philip

Office of Performance Improvement

Head & Neck Center

MD Anderson Cancer Center

Located in Houston, TX Found in 1941 20,000 Employees (1,600

faculty) 650 inpatient beds 1.3 M outpatient visits Provided care to 120,000

patients in 2013• Ranked Number 1 in

cancer care by U.S. News and World Report

HN Center

Approach: Engagement and Integration

Strategic Planning

Physician/Center Leadership-Led Teams

Monthly Accountability Reviews

OPIDepartments

HNS, HNMO, RT

Participants

Head and Neck Center:• Laura Baker, Ursula Broussard, Gloria Brown, Sheila Harris, Hettie Hebert, Eve Huang, Sharon Jamison, Grady Johnson,

May Johnson, Rita Langner, Shirley McKenzie, Judy Moore, Maria Morales, Julie Ngo, Mary Penkwitz, Marie Pope, Letitia Reed, Missy Robinson, Marvin Saavedra, Shalamar Spears, Estie Thompson

Head and Neck Surgery:• Kerith Brandt, Ehab Hanna, M.D., Amy Hessel, M.D., Stephen Lai, M.D., Carol Lewis, M.D., Jeff Myers, M.D., Justine

Robinson, Shawn Terry, Abram Trigazis, Randal Weber, M.D.

Head and Neck Medical Oncology:• Michele Neskey, Karen Oishi

Radiation Oncology:• Beth Beadle, M.D., Amanda Coldiron, Jennifer Gates, Hamlin Williams

Office of Performance Improvement:• John Bingham, Laura Burke, Parviz Kheirkhah, Victoria Jordan, Miguel Lozano, Jeremy Meade, Pheba Philip, Larry

Vines

Marketing:• Cecilia Kenneally, Gelb Consulting

Clinical Operations:• Kathy Denton

Background

Head and Neck Center formed a partnership with the Office of Performance Improvement to:

• Define a series of performance improvement initiatives to enhance the patient experience

• Align projects with Institute of Medicine aims:

• Safe• Effective• Patient-Centered

• Timely • Efficient• Equitable

Initiatives

1. New patient access time Timely First contact to initial appointment

2. Overall patient cycle time Timely Time gaps in treatment

3. Clinical variation and overuse of testing

Effective, Efficient

Duplication and inconsistent use of diagnostic imaging services and lab tests

4. Patient interviews Patient-Centered

Gather the voice of the patient to capture expectations, preferences and concerns

5. Staffing model development

Efficient Part of the current RN staffing model development in the ambulatory care centers

Team LeaderSheila Harris

Patient Access Supervisor,Head and Neck Center

New Patient Access Time

Faculty LeaderCarol Lewis, M.D.Assistant Professor,

Head and Neck Surgery

FacilitatorPheba Philip

Industrial Engineer, Performance Improvement

MembersHettie Hebert (PAC), Shalamar Spears (PAS), Judy Moore (CAD), Jeremy Meade (OPI)

300+ New patient referrals per month

200+ New patients registered per month

New Patient Access

Emphasis on appointment coordination

Since FY10, 10% increase in other appointments required to coordinate with NP appointment

Project AIMS

Reduce referral (first contact) to appointment date, including medical and financial clearance, from 12 days to consistently under 10 days

NP Access

Cause and EffectNP Access

Main Interventions

Enforced 24-hour rule for referral

acceptances by faculty

(no exceptions)

Faculty commitment to require minimal

acceptance criteria

(don’t delay acceptance based on inadequate

outside records)

Enforced timely filing of delay indicators and educated PAS on the

importance

(patient preference, insurance pre-approval, financial/social reasons)

Trained PAS staff on round robin approach

to assigning appointments to

physicians

Process for immediate redirecting

referrals to a more appropriate physician,

avoiding patient acceptance delays

Standardized patient appointment templates

in CARE to facilitate scheduling

NP Access

Improvement of Metrics

20.0

17.5

15.0

12.5

10.0

7.5

5.0

Month

Days

Baseline Post intervention

_X=11.53

_X=8.21 _

X=7.36

11

H&N Center - Referral to Appointment

• Timely filling of delay indicators

• PAS education & training• Enforced 24-hour rule

• Trained/Re-educated PAS staff on round robin approach

• Standardized new patient appt durations on templates

• Reinforced email policy for redirecting referrals to other physicians

• Corrected CARE default time issue for next available appointment

• HC Transfers

• Low sample size sensitive to outliers

NP Access

Keys to Sustainment

Continued support and monitoring from department chair, medical director and CAD

PAC monitors and communicates open appointment slots regularly

PAC audits charts for accuracy, completeness, and compliance of expectations of 3-5 day appointments

Actively monitor % of patients who fall outside of the standard time for testing (3-5 days)

NP Access

Team Leader

Judy MooreClinical Administrative Director,

Head and Neck Center

Clinical Variation & Overuse of Testing

Faculty Leader

Amy Hessel, M.D.Professor & Chair, Head and Neck

Surgery

Facilitator

Laura BurkePerformance Improvement Associate

MembersJeremy Meade (OPI), Laura Baker (PAS), May Johnson (CBM), Hamlin Williams (PSC), Missy Robinson (PSC), Eve Huang (RN), Julie Ngo (RN), Dr. Beth Beadle (XRT Faculty), Karen Oishi (APN), Justine Robinson (PA), Abram Trigazis (PA), Michele Neskey (PA), Amanda Coldiron (PSC), Jennifer Gates (RN, NM XRT)

• Standardize the treatment planning and follow up schedules for all HNS cancer patients requiring multidisciplinary care including oropharynx, larynx and hypopharynx

• Reduction of redundancy of imaging and laboratory tests

• Increase efficiency and decompress the volume of the clinics

• Improve patient satisfaction: fewer appointments and decreased wait times

• Facilitates accommodation of new patients and greater focus on patients with acute care needs

AimsClinical Variation

Baseline Data:After 6 months (Post radiation summary date)

• 43% of appts are within 3 months of last appt

• 11% of CT scans are within 3 months of last scan

Clinical Variation

Less than 1 Week

1 Week - 1 Month

1 - 2 Months

2 - 3 Months

3 - 6 Months

6 - 9 Months

9 - 12 Months

More than 1 Year

0%

10%

20%

30%

40%

50%

60%

18%

7% 6%

13%

45%

9%

1% 1%0.5% 0.8% 1.1%

8.5%

55.9%

21.7%

5.5% 5.9%

Time Between Appointments and CT Scans (Soft Neck Tissue)

Appointments CT Scans

Time Frame

Per

cent

of A

ppoi

ntm

ents

Main Interventions

Identified critical timing for follow up &

treatment decision-making

Defined minimum testing needed for

appropriate work-up & follow up

Standardized order form to include

predefined testing

Assigned equal responsibility for

patient outcome & complications to all the

treating teams

Provided training for providers, schedulers,

and nurses

Created patient education sheet to

better inform patients about the benefits of

the COC pathway

• Developed a “leap frog” system for follow up appointments after completion of treatment

– 3 Month Follow Up Radiation Oncology– 6 Month Follow Up Medical Oncology– 9 Month Follow Up Surgery– 12 Month Follow Up Radiation Oncology– 16 Month Follow Up Medical Oncology– 20 Month Follow Up Surgery– 24 Month Follow Up Radiation Oncology– After 2 years Survivorship

• Allows patient to have one appointment and one set of tests rather than follow up with each provider team independently

Continuity of Care PathwayClinical Variation

Patient Report Card

Patient Report Card

• Given out by HNS after the evaluation for surgery

• Allows for patient responsibility

• Allows for equal ownership of post treatment follow up

• Allows for expectation of transition to survivorship

Clinical Variation

Transition to Follow UpClinical Variation

Standardized CSR to include predefined testing

Faculty Involvement

Target = 24

May

-11

Jul-1

1

Sep-1

1

Nov-1

1

Jan-

12

Mar

-12

May

-12

Jul-1

2

Sep-1

2

Nov-1

2

Jan-

13

Mar

-13

May

-13

Jul-1

3

Sep-1

3

0

5

10

15

20

25

30

Faculty with COC Appointments

Providers

Target

Month

# F

acu

lty

• Faculty involvement has increased

• 65% eligible patients are on pathway

Clinical Variation

Current = 22

Preliminary Trends/ResultsClinical Variation

Appointments 28% reduction in appointments within 3 months of past appointment

37% of eligible patients are expected to have a reduction in total number of appointments

Testing Patients are receiving standard labs and imaging

As participation increases, expect to see reduced variability in imaging

Team Leaders

Judy MooreClinical Administrative Director,

Head and Neck Center

Patient Wait Time

Faculty Leaders

Ehab Hanna, M.D.Professor & Medical Director, Head

and Neck SurgeryRandal Weber, M.D.

Professor & Chair, Head and Neck Surgery

Facilitators

Miguel LozanoSr. Quality Engineer, Performance Improvement

MembersKerith Brandt (PA), Marvin Saavedra (PSC), Jeff Myers, M.D. (HNS), Carol Lewis, M.D. (HNS), Grady Johnson (PSC), Shawn Terry (PA), Mary Penkwitz (RN), Julie Ngo (RN), Amy Hessel, M.D. (HNS)

Patient Wait Time

• Identified lowest wait time performers• Documented best practices• Analyzed template and scheduling practice and its

impact on wait time

Wait Time

Define

Measure

Analyze

• Defined the problem• Observed and documented patient process flow• Identified patient characteristics and expectations for

each appointment type

• Collected baseline patient wait time data for all physicians

Classic PI approach using the DMAIC process

Patient Wait Time

Preliminary findings to be trialed• Reinforce & prioritize best practices around team communication,

scheduling decisions, and startup/preparation activities.

• Avoid appointment clusters in same time slots

• Spread NP appointments throughout the day

• Make scheduling arrangements for high need patients

0

50

100

150

200

250

Min

utes

Appointment Time

Wait time to see Physician

Wait time to see Physician

Linear (Wait time to see Physician)

CO

NP

NP

NP

NP

NP

CO

NP

NPNP

Improve

Control

Wait Time

• Earlier start time• Reduced

appointment clusters

• New patients spread during day

• Improved schedule load leveling

Scheduling Changes

Baseline Improvement Baseline ImprovementProvider A Provider B

0

20

40

60

80

100

120

140

122

58

8370

Average Patient Wat Time

Wait Time

Team LeaderJudy Moore

Clinical Administrative Director,Head and Neck Center

The Patient’s PerspectiveOpportunities for Improvement Through Patient Interviews

Faculty LeaderEhab Hanna, M.D.

Professor, Head and Neck Surgery

FacilitatorCecilia KenneallyManager, Marketing

MembersGelb Consulting, May Johnson (CBM), Shirley McKenzie (CCC), Jeremy Meade (OPI), Ehab Hanna, MD (HNS Faculty)

Patient Interviews

• 41 interviews were completed with patients from June 11 – June 22, 2012. Interviews conducted by Gelb Consulting through Marketing.

• Interviews were completed on site at the Head & Neck Center. On-site interviews provide visual cues for recall.

• Some patient interviews included family/caregivers, revealing unique roles and needs.

• Discussion areas:– Decision criteria– Scheduling– Wait times during and between appointments– Experience with treatment team– Communication processes and gaps– Sources of anxiety– Areas of praise

Patient Interviews

Head & Neck Center Patient Experience Map

Symptoms

Diagnosis

Awareness of MD Anderson

Evaluation of healthcare providers

Reputation of MD Anderson’s Specialists

Choose healthcare provider

Scheduling first visit

Resources for patients and their families

Scheduling and intake

Treatment/exam room

Chemotherapy, Radiation Treatment, Surgery

Nursing care, Physician care

Support groups and wellness services

Communication with referring physician

Follow-up visits

Call-backs for assistance

Parking

Getting to Head & Neck Center

Checking-in

Waiting area, including vitals

Clinic faculty/staff interactions

Need Scheduling First Visit Treatment Follow Up

Primary Experience Stewards

• MDACC Faculty/Staff• Patients and their

Families

• Front Desk Staff• Faculty/Medical Staff

• Faculty/Medical Staff• Support Staff

• Faculty/Medical Staff• Support Staff

• Faculty/Medical Staff• Support Staff• Patient’s Primary

Physician

Key Touchpoints

Patient Interviews

Action Item Summary

Need Action Lead Comment Status

Strengthen relationship with referring/primary care physicians

Send personalized thank you note to patients' referring physicians

Dr. HannaLetter complete. Next step is to gather faculty preferences on who to send to (all on cc list or patient preference)

In-progress

Actively get referring physicians connected to myMDAnderson

Include w/communication (thank you note) to referring physicians

Judy Moore

Will be included with letter

Adopted process - PAC checks/validates referring physician in system. July Physician Communication Initiative Report increased to 100%

In-progress

Improve coordination of out of town patients and set expectations to patients needs

Improve BC practice of coordinating out of town appointments to a standard of 3-5 days for HNS and up to 7 days for HNMO

Judy Moore

Adopted process:PAC audits charts for accuracy, completeness, and compliance of expectations of 3-5 day appointmentsActively monitors % patients that fall outside of the standard time for testing (3-5 days)

Complete

Ensure we are providing clear, consistent information prior and duration patient visits

Work with Patient Education to better leverage patient and staff resources

Judy Moore

Met with Patient Education. Options to consider:1) Provide patient with patient education flyer or post in center/exam room2) Provide patient with flyer about patient orientation course or post in center/exam room3) Re-train staff about benefits/offerings of Patient Education Center (take tour, CEU credit?)4) Allow patients to take on-line orientation course on exam room computer

In-progress

Improve patient communication about treatment options

Work with Patient Education to better leverage patient and staff resources

Judy Moore See above

Continue to compress appointments and improve coordination between services

Leverage Continuity of Care project Dr. Hessel Current, on-going project team On-going

Decrease appointment wait times and improve communication when wait times exist

Leverage Wait Time project OPI - Miguel Lozano Current, on-going project team On-going

Patient Interviews

Ambulatory Nursing Staffing Model

• Nursing Personnel Staffing Model was developed to help leadership:

– Make staffing decisions based on data

– Make sure resources are properly allocated

– Analyze “what-if” scenario for improvement initiatives

Keys to Success

Combined engagement of OPI, academic department, and center leadership

Strategic planning upfront to align projects to goals

Monthly accountability meetings with steering team

Physician participation/leadership on teams

Questions?